PHAMILY EYE CARE

Today's Date

MonthDayYear
Full Name
Age
Date of Birth
Gender
Street Address
City
State
Zip Code
Cell Phone Number
Format: (000) 000-0000.
Email
Occupation
Employer
Primary Care Doctor
Doctor's Phone#/Address
Preferred Pharmacy
Pharmacy Phone#/Crossroads
Emergency Contact Name
Emergency Contact's Phone#
Format: (000) 000-0000.
Relationship to patient
Preferred method of communication:
Is patient a minor (under age of 18)?
Guardian name
Relationship to patient
Guardian Phone #
Please enter a valid phone number.Format: (000) 000-0000.

Insurance Information
Who is your vision insurance provider
Policy / ID number
Is patient the primary for insurance?
Name of primary:
Primary's birth date:

MonthDayYear
- Disclosure of Health Information
  
  I authorize release of my health information to the following person(s)/healthcare provider:
- Name (1)
- Relationship to patient (1)
- Phone/Email (1)
- Name (2)
- Relationship to patient (2)
- Phone / Email (2)
- Office Policies
  
  Financial Agreement & Acknowledgement of Receipt of Notice of Privacy Practices
  
  I understand that all services rendered to me and charged are my personal responsibility for timely payment: including co-payments, deductibles, and non-covered services remaining after my insurance has paid. I understand that it’s my responsibility to know my insurance coverage. I authorize use of the signature on this form for insurance claim submissions, and for insurance to be filed on my behalf based on the information given on the date of service. I also authorize release of my medical information via email and understand it may be unsecure.
  
  I understand that there are NO refunds on professional fees, and that follow-up visits outside 30 days will incur a fee.
- Notice of Privacy Practices
- Please select all of the following to indicate your understanding:
- Signature agreeing to all above terms
- Date
  
  MonthDayYear
- Should be Empty: